Viagra Creep

Viagra Creep

Quality-of-life drugs may threaten more than insurers.

The craziest idea coming out of the Viagra frenzy is that it's somehow scary and wrong for health insurers to limit reimbursement for the drug. Many insurers will pay for the erection wonder pills only for men who are tested by a urologist and proved to have organic--not psychological--erectile dysfunction. Some insurers are also limiting the number of pills they will pay for to 10 each month, some even fewer, and a few none at all.

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Commentators on talk shows and news programs are incensed by the limits (although no one yet complains that Medicaid programs are likely to refuse reimbursement altogether). "Get the insurers out of our bedrooms!" is the rallying cry. But not so fast. As Dr. Michael O'Leary, a Harvard urologist and expert on sexual dysfunction, told the Wall Street Journal, "I'm not convinced that it's a God-given right to have an excellent erection."

Viagra is just the latest in the boom of "quality of life" technologies that aim to enhance--rather than save--lives. Such treatments as Viagra, Propecia for hair loss, and fertility treatments pose a distinct problem for insurers. True, the treatments address biologically caused problems, but ones that are hardly incapacitating. Still, there is no clear distinction between these disorders and such accepted medical problems as acne or vitiligo (a disorder of skin pigmentation). If severe enough, even wrinkling or hair loss can be considered medical problems. So these new drugs erode accepted distinctions between worrisome abnormalities and the normal variations of human life. While the drugs push in one direction, the insurers push in the other.

Before Viagra, the hoist and pull mechanics of previous impotence treatments--inflatable penile implants, Caverject erection injections, and vacuum devices--made them unattractive to most men, impotent or not. Viagra, by contrast, is simple and offers discretion. Instead of creating erections on its own, it amplifies the signals men's bodies already have. (The mechanics of Viagra have been widely reported. Click for a reminder.) The results in impotent men are better, longer lasting erections and more satisfying sex.

These effects might also occur in perfectly able men. Some are already seeking the drug in the hope that they can sustain repeat performances--and they're filing claims. One HMO executive even had a claim from a young man for a Viagra prescription he had procured to enhance his wedding-night performance. At the very least, insurers should be allowed to distinguish these kinds of claims from others.

Tougher cases became evident to me during a visit I made to O'Leary's urology clinic. That afternoon, some two dozen patients ranging from 21 to 86 years of age were lined up for Viagra. I joined him in seeing a few. Each patient bashfully left the impotence literature and Playboy magazines in the examining rooms untouched. (O'Leary is one of the few Americans who can take a tax deduction for pornography.) But the urologist didn't beat around the bush. "Are you here for Viagra?" was his opening question to each patient. Everyone replied yes, seeming relieved to have the doctor raise the subject.

One patient, I'll call him George Davis, was around 60, obese, and hadn't had sex with his wife in over three years because of difficulty getting erections, a problem almost certainly related to his diabetes. At some age, most people would say impotence is normal. As many as 30 percent of 65-year-old men and probably over 50 percent of 75-year-olds are unable to "obtain and/or maintain a satisfactory erection for intercourse." Before Viagra, many weren't quite ready to accept their decline, but few were ready to accept the treatments. Sex wasn't important enough. So, insurers were happy to let men define for themselves whether their impotence was worrisome or not. Now a little blue pill might do the trick. Davis wasn't sure if he was willing to pay $10 a pop. But he figured his insurance would cover it, so why not give it a try? Davis was a walking demonstration of every insurer's nightmare.

We don't think people should have to worry about cost when deciding whether to undergo treatment for cancer or arthritis. But for the life-enhancing technologies, there's nothing wrong if insurers say that, at some point, cost should come into play. If Davis is willing to pay $10 for, say, a bottle of wine but not for sex, why should the insurer pay? If these expensive new drugs were free, people would demand amounts out of all proportion to the value they actually place on them.

But quality-of-life drugs have social side effects that are potentially more troubling than the cost strains. The sneaky thing about Viagra, for example, is that it's so straightforward it makes not treating impotence seem as strange as not treating pneumonia. Viagra lowers the bar on what's medically abnormal. Indeed, all the quality-of-life drugs do. In a current ad barrage, manufacturers encourage people to "ask your doctor" about drugs for unsightly nails. The prescription skin cream Renova is hawked for wrinkles. Bristol-Myers Squibb is testing a drug to reverse sun damage in skin. And, of course, who can miss the ads for Propecia? All these drugs treat problems that most people hadn't considered medical before.

Insurers will try, as they must, to counter the tendency of quality-of-life drugs to redefine abnormality upward. But the insurers are fighting an irresistible force. The drugs play on the inevitable--some say genetic--human desire for youth and immortality. As each new drug is released on a wave of hype, insurers will fight the deluge, but patients will clamor, and doctors will go along.

The transformation of normal to abnormal may start with a pill. But the physician's need for diagnosis is what drives the process. Since the new quality-of-life drugs can have adverse health effects, the drugs need to come through physicians. But we don't give out drugs willy-nilly. We must provide a medical reason--a diagnosis. So we call impotence "erectile dysfunction," baldness "hypotrichosis," and so on. The rapid increase in attention-deficit disorder is a striking example of diagnosis creep. The disorder hardly seemed to exist before the stimulant Ritalin came along. A core group of kids do have a distinct attention abnormality, but Ritalin worked so well--it can reduce distractibility even in perfectly normal children--that now almost any "difficult" child is considered for the diagnosis and drug. A 1990 study found that 28 percent of children diagnosed with the disorder didn't actually meet the definition. Nevertheless, the percentage of children on Ritalin has doubled since then.

By giving a patient's condition a medical name, we turn it into a medical abnormality. That creates a presumption that insurers must pay. It also creates a presumption that it will be treated. If I write a new diagnosis in a patient's chart, I have to indicate what I plan to do about it. It'd be malpractice not to. More than that, once a condition is established as a diagnosis, society practically treats it as a crime not to do something about it.

This raises an ironic prospect. Quality-of-life drugs offer not just the pleasing possibility that you can do something about impotence, baldness, blackened toenails. They create a culture in which you must fight against these conditions--even if it means risking serious side effects (the anti-fungal drugs for nails can damage the liver, Propecia's anti-testosterone action can decrease libido). By their sheer effectiveness, the quality-of-life drugs narrow the range of what society accepts as normal. In doing so, they may ultimately reduce the quality of life for the many of us who are less than perfectly endowed.